Which nursing diagnosis is appropriate for a patient who insists being called "Your Highness" and demonstrates loosely associated thoughts?
a. Risk for violence
b. Defensive coping
c. Impaired memory
d. Disturbed thought processes
ANS: D
Delusions and loose associations suggest disturbed thought processes. The other options are not supported by data in the scenario.
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While assessing a preschool-age child at play, which behavior indicates that the child is successfully moving through Piaget's cognitive stages of development?
1. The child is able to consider the differing opinions of playmates. 2. The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week. 3. The child reports being able to rationalize why it is better to eat fruit than candy. 4. The child understands that his mother loves him as much as she loves the child's older siblings.
Contributing factors in HIV development in the older adult include all of the following except
A. Older adults are less likely to be tested B. Healthcare providers do not routinely ask older adults about HIV risks C. Older adults are less likely to use condoms D. Older adults are at low risk to contract HIV
A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse?
A. Assessing the client's level of anxiety B. Assessing and documenting the client's vital signs C. Assessing suicide risk D. Assessing availability of support systems
A new client has been diagnosed with schizophrenia and is exhibiting immobility, rigidity, and stupor. What subtype of schizophrenia is this individual most likely suffering from?
A) Disorganized B) Catatonic C) Residual D) Paranoid